Shock Risk

Shock Risk

Introduction for Nursing Diagnosis: Shock Risk

Nursing diagnosis is a core tool used in the nursing practice to define and classify the health problems of patients that can be addressed by the nurse. Shock Risk is one commonly used nursing diagnosis. It is important for nurses to correctly assess the risk of shock and intervene appropriately by implementing measures to prevent and decrease the risks associated with shock.

NANDA Nursing Diagnosis Definition

Shock Risk is defined as the at-risk state for tissue hypoperfusion that results from an inadequate supply of oxygen and nutrients necessary for cellular metabolism.

Defining Characteristics

Subjectives

  • Verbal reports or indicators of fear or anxiety
  • Cognitive deficits regarding understanding and awareness of danger
  • Lack of knowledge regarding effective preventive strategies related to specific disease processes

Objectives

  • Poor capillary refill
  • Hypotension
  • Altered mental status
  • Rapid pulse
  • Pale, cool skin

Related Factors

  • Inadequate tissue perfusion due to acute illness
  • Lack of knowledge about treatment regimen for compensatory strategies for shock risk management
  • Environmental hazards or disasters
  • Impaired immunologic defense mechanisms
  • Age-related physiological changes

Risk Population

Patients who are at risk for shock include those with pre-existing conditions such as hypertension, vascular disease, cardiac disease, diabetes mellitus and dehydration. In addition, high-risk populations include older adults, neonates and children with congenital heart defects and those with multiple traumas or recently admitted to an intensive care unit.

Associated Problems

If shock risk is left untreated it can lead to organ failure, tissue necrosis, and death.

Suggestions of Use

It is recommended that nurses utilize emergency interventions to prevent, reduce and manage the risk of shock. These interventions should include monitoring vital signs, tissue perfusion, fluid and electrolyte levels, preparing for intubation and emergency resuscitation measures.

Suggested Alternative NANDA Diagnoses

  • Activity Intolerance: A sensation of exhaustion and fatigue associated with the inability to tolerate a normal or desired level of activity
  • Ineffective Tissue Perfusion: Impaired circulation to tissues or areas of the body
  • Imbalanced Nutrition: Less than body requirements
  • Acute Pain: Sudden, sharp pain caused by injury, illness, or inflammation

Usage Tips

When caring for patients with Shock Risk NANDA diagnosis they must remain the focal point of all interventions implemented. Vital signs should be monitored closely and any signs of deterioration should alert the nurse to initiate Emergency Action Plan to prevent tissue hypoperfusion and risk of shock. Documentation should include assessments of patients vitals, treatments, interventions and education given to patient. Patient discharge instructions should also be provided.

NOC Results

  • Tissue Perfusion: measure of oxygen and nutrient delivery to tissue cells
  • Nutrition: intake, absorption and utilization of nutrients
  • Fluid Balance: maintenance of fluid, electrolytes and pH balance
  • Tissue Integrity: general integrity of skin, mucous membranes and other organs

NIC Interventions

  • Infection Process management: implementation of interventions to prevent and reduce risks of infection
  • Early Warning Signs Recognition and Intervention: assessment, recognition and response to signs and symptoms of shock
  • Cardiovascular Management: implementation of intervention to maintain adequate blood pressure, perfusion and ventilation
  • Patient Teaching: provide patient and family teaching about shock risk, effects, prevention and management

Conclusion

Shock Risk is a serious condition that requires immediate medical attention. Nurses should assess patients’ risk of shock and intervene appropriately to prevent and manage the risk. NANDA Nursing Diagnosis, NOC Results and NIC Interventions are vital tools to assist the nurse in accurately assessing, intervening and documenting patient care.

FAQ

  • What is shock risk nursing diagnosis?
  • Shock Risk is a nursing diagnosis defined as the at-risk state for tissue hypoperfusion that results from an inadequate supply of oxygen and nutrients necessary for cellular metabolism.

  • What are defining characteristics for shock risk nursing diagnosis?
  • The Defining Characteristics for Shock Risk nursing diagnosis include verbal reports/indicators of fear or anxiety, cognitive deficits related to understanding and awareness of danger, lack of knowledge about effective preventive strategies, poor capillary refill, hypotension, altered mental status, rapid pulse, and pale, cool skin.

  • What are NOC Results and NIC Interventions associated with Shock Risk nursing diagnosis?
  • NOC Results associated with Shock Risk include Tissue Perfusion, Nutrition, and Fluid Balance, whereas NIC Interventions include Infection Process Management, Early Warning Signs Recognition and Intervention, Cardiovascular Management, and Patient Teaching.

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